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Oleg I. Reznik, M.D. Board Certified Family Physician |
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Assistant Professor at OHSU Department of Family Medicine |
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The Secrets of Medical Decision Making: How to Avoid Becoming a Victim of the Health Care Machine By Oleg I. Reznik, M.D. Foreword by Colin P. Kopes-Kerr, MD, JD, MPH |
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Comments, Responses, Updates 1/24/06 Several people have asked me to clarify the concept of Number Needed to Treat, or NNT, which is presented in Chapter 16, Illusions of Medical Omnipotence, on p.123. Indeed it can be a challenging concept to grasp even for the professionals. It is simply a quantitative way of expressing how much benefit one can expect from a given treatment. When we take a medication we generally expect that it’s doing us good. But how much good is it doing? Is it doing enough good to be worth it to go through the trouble of taking it? Here is one example that isn’t in my book, but that is very pertinent and came out very recently (March 2005).1 People who do not have heart disease are now advised (it’s part of the guidelines) to take cholesterol-lowering medication and by thus lowering their cholesterol decrease their risk of heart disease. Many readers are taking it just for this very reason. This is called Primary Prevention. PRIMARY, because you do not have the disease yet. If you already had heart disease (heart attach or heart disease demonstrated by tests), and were taking medication to prevent further damage, it would be called SECONDARY prevention. So, how much benefit can you expect from the Primary Prevention of heart disease by taking a cholesterol-lowering medicine? One way of answering this question is to state how many heart attacks would be prevented by taking it for a year of more than one year. This very question was answered by recent studies. The answer is that 60 patients have to take a cholesterol-lowering medication for 5 years in order to prevent ONE cardiovascular event (heart attack and/or angina attack). To give this a better perspective, imagine yourself standing out there in a group of 60 persons. If all of you (all 60) would take cholesterol lowering medication for 5 years, you would all prevent a total of one heart attack. This if one heart attack for all of you, not for each of you. One of your fellow persons (one from your group of 60) would have one heart attack prevented. Most people are very underwhelmed when they find this out. By the way, there was no reduction in ‘overall or cardiovascular mortality’, meaning that none of the 60 of you will live any longer, even the one whose heart attack was prevented isn’t going to have a longer lifespan. The medication is only going to save him the troubles and pains of that one heart attack. All of this, of course, is in statistical terms, which is all that studies can tell us. Studies can never tell how any particular individual will do. Nevertheless, studies is what is used for creating medical guidelines. So, Number Needed to Treat (or NNT) for the treatment of elevated cholesterol as a primary prevention of heart disease is 60, with the duration of treatment of 5 years and the outcome of preventing one cardiovascular events . In spite of this minute benefit (considering all the trouble involved in having 60 people take a medication for 5 years) the 2001 report of the National Cholesterol Education Program expert panel estimated that 36 million U.S. adults should receive drug therapy for the treatment of elevated cholesterol. See Political Facts section of this web site for information on what may have influenced this panel of experts in their decision making regarding drug treatment of cholesterol. Hope this helped.
References: 1. Lockman, Andrew R, MD; Tribastone, Andrea D, MD; Knight, Karen V, MSLS; Franko, John P, MD. Treatment of Cholesterol Abnormalities. American Family Physician. Vol. 71, Num. 6, March 15, 2005.
7/7/06 Controversy Surrounding Screening Mammography While I mostly get a very positive feedback, I number of people voiced their concern about my views of screening mammography. Objections usually come from breast cancer survivors who believe that they are surviving BECAUSE OF screening mammography and ensuing treatment. From the evidence available to date, I can only conclude that that the survivors should be thankful to anything but screening mammography and that they are surviving not because of it but IN SPITE of it. I say this because the studies done so far show a small reduction in breast cancer mortality (15%), but show no reduction in total mortality. In other words, women who get treated for tumors discovered by mammography die of something else, often something that is a consequence of treatment, without reaping any longevity benefit. The findings are still controversial and inconclusive, but what is known for sure, is that screening mammography comes with numerous side-effects (see below). Several variables play a role in creating this strong belief in the importance of medical intervention. First, screening mammography finds a great deal of ‘microcalcifications’, a finding seen in the pre-cancerous condition called DCIS (ductal carcinoma in situ). It is known that some of DCIS regress spontaneously, some remains unchanged for the rest of person’s life, and some progress to cancer. All women with DCIS are lead to believe that they had cancer and that by removing the lump with DCIS they were cured. After that they believe that their lives were saved by the mammography. In reality, the majority of these women never would have developed cancer in the first place. They only underwent unnecessary treatment. Another scenario is when a true invasive cancer is discovered and treated after which there is a lasting remission. To assume that the remission is due to medical intervention is also erroneous. Breast cancer, especially later in life, tends to be indolent and many persons would likely remain alive without any medical treatment for 10, 20, or more years. Third, there is something to be said about the power of human spirit and about spontaneous cure. These cures have been well documented in the past, but nowadays, if such a cure was to happen, it would likely happen while the person undergoes treatment. That very person later attributes all of the credit for the cure to the medical treatment, forgetting those other important, intangible, and difficult to explain factors. The organized media campaign instills the belief that screening mammography saves lives, and public events, organized by the oncological and radiological medical societies (all of which have a vested interest in having larger numbers of clients) tend to create and attract genuine but uninformed believers, who then passionately promote screening out of best intentions. Below is the information leaflet that mentions the side effects and possible (though not definitively proven) benefits of screening mammography. I would encourage every woman that is considering to undergo screening mammography, to read these and decide for herself whether she wants to have the procedure. The leaflet does not mention the risk of acquiring cancer as a result of repeated exposure to X-ray radiation from mammography. This risk, though small, is present. Finally, besides a minority of physicians, who like myself, do not believe that screening mammography is of value, a group of women, some of whom are cancer survivors, have also concluded the same. Look at the National Breast Cancer Coalition web site (http://www.natlbcc.org/) and see their statement, which reads: NBCC believes that there is insufficient evidence to recommend for or against screening mammography in any age group of women. Women who have symptoms of breast cancer such as a lump, pain or nipple discharge should seek a diagnostic mammogram. The decision to undergo screening must be made on an individual level based on a woman's personal preferences, family history and risk factors. Mammography does not prevent or cure breast cancer, and has many limitations. Women are told that mammography screening saves lives, but the evidence of a mortality (death rate) reduction from screening is conflicting and continues to be questioned by some scientists, policy makers and members of the public. Here is information from a leaflet put together by European researchers. Main benefits and harms, assuming a 15% reduction in breast cancer mortality and overdiagnosis of 30%. If 2000 women are screened regularly for 10 years: 1 woman will avoid dying from breast cancer 10 healthy women, who would not have been diagnosed without screening, will have breast cancer diagnosed and be treated unnecessarily; 4 of these will have a breast removed, 6 will receive breast conserving surgery, and most will receive radiotherapy 1800 will be alive after 10 years; without screening 1799 will be alive. Other main points Of 2000 women (in Europe) who participate in 10 rounds of screening 500 will be recalled for additional investigations because cancer is suspected; about 125 will have a biopsy 200 will experience psychological distress for several months related to a false positive finding Screening can provide false reassurance. Up to 50% of cancers among women in screening programmes are detected between two screening rounds, and these interval cancers are the most dangerous Mammography is painful for about a third of women
I should add that rate of screening and rate of recalls (requests to return for more X-rays) is higher in the US than in Europe.
Source of the leaflet: Karsten Juhl Jørgensen, Peter C Gøtzsche, Content of invitations for publicly funded screening mammography. BMJ 2006;332:538-541 (4 March).
The most recent interview with wsRadio is available at: http://www.wsradio.com/internet-talk-radio.cfm/shows/Coping-with-Caregiving/archives/date/selected/09-22-2007.html Click here to hear some of my other radio interviews or go to the publisher’s website at http://audio.authorsaccess.com/ |
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ISBN 1-932690-16-6 Published by LovingHealingPress
Synopsis: I wrote this book with an intention to encourage the reader to be more self-reliant and independent, when it comes to medical decision making. While the book does have an “exposé” tone to it, it was written that way not for the sake of exposé per se, but as a means of illustrating why independent decision making, self-reliance, and respect of one’s own values and judgment are indispensable for anyone seeking health. Each chapter not only illustrates problems, but also the ways of solving them, by the prospective patient or patient’s relative. A shift of an attitude, from that of blindly following a physician and believing in the omnipotence of the system to that of critical examination and personal decision making is the key. This book is about all the non-medical elements that go into medical decision making of a physician today in the US. Inappropriate and harmful medical treatment often happens when patients are either unable to make decisions, as in dementia or advanced disease, or they give carte blanche to the doctor to make all decisions for them. Because of the various conflicts of interest that I describe in this book, not many doctors are actually able to act entirely to the patient’s benefit. It is a challenge to the best of physicians. I believe that the patient or family must accept and exercise the responsibility of decision-making. They must not be shy about expressing their preferences or asking questions; they need not be concerned about what someone else will think. They owe it to themselves to articulate their preferences openly and clearly. You may be surprised to find out what runs through your doctor’s head during an office visit, or while treating patients at a hospital. Besides what one might expect—ideas about what has caused the patient’s suffering and what the appropriate treatment would be—most physicians feel forced to juggle a number of considerations, many of which have nothing to do with benefiting the patient. You may have experienced the signs of this inner conflict in a variety of doctor-patient situations, and may have even encountered some of the unfortunate consequences. It may be seen in relatively benign instances, when you may feel pressured by the doctor to take a certain medication, and in more serious ones when you are being persuaded or convinced to undergo tests, procedures and treatments that will really only make your doctor feel safer and more reassured, while possibly causing you harm. Doctors are secured from liability by following the guidelines of the health care authorities—agencies that create medical guidelines. These agencies are influenced by the medical industry. This industry, while creating many valuable things, operates according to the laws of business, laws that lack compassion. In our litigious age, the doctor feels protected when he’s been following guidelines, regardless of what happens to the patient. Because of this and other reasons, your doctor is no longer simply your advocate. In this book, among other things, I expose how the industry exerts its influence on the medical guidelines, medical education, and consequently, medical practice. Awareness of this can prevent some of the unnecessary suffering that is inadvertently inflicted by our current health care system. It can also reduce the cost of health care which has been growing out of proportion in our race to fulfill the false hope of making us immortal by the use of technology. Within the framework of the current medical system, the patient’s and the physician’s perspectives are explored, and the impact on society as a whole. When we seek medical advice we’re hoping that a physician will always offer us what is in our absolute best interest. Indeed many physicians attempt to do that and some actually do. It is my perception however that great many physicians are bound by what I would call the Four Corners of the Medical Box. They are: Fear of litigation Financial and time pressures Guidelines of Health Care Authorities The current Medical Model What propels a physician to leave this box by going beyond the boundaries of personal security? The elements are: genuine compassion, desire to do what is in patient’s absolute best interest, and courage to take the necessary risks. In this book, all of these elements are considered and illustrated with specific examples I encountered in my training and practice. Practical and sobering recommendations are offered for patients and their families. As a family physician practicing general adult and pediatric medicine and doing low risk obstetrics, I am intimately in touch with a full range of medicine from a newborn to an elderly, from an outpatient clinic to an Intensive Care Unit of the hospital. This permits me to explore more closely how the above mentioned boundaries are instilled during training and played out in practice, with their effect on the patient. In this book I also provide numerous specific examples of the most frequently encountered medical situations such as screening mammography, cervical cancer screening, prostate cancer screening, mode of childbirth, prenatal screening etc. All are described as vignettes of actual patients whom I encountered during my practice and training. I share the thinking process of a physician and offer a practical way of avoiding the pitfalls of the current medical system. I attempt to reveal a more realistic picture and capabilities of medicine, and to remove the myth of medical omnipotence. This myth, developed by the medical industry and popularized by the media, results in a myriad of unrealistic expectations in the public leading to unnecessary suffering and disappointment.
Psychologist, writer, author of several books, and editor Dr. Bob Rich wrote: The Secrets of Medical Decision Making: How to avoid becoming a victim of the Health Care Machine’ is an important book. It should be read by everyone, because all of us are sometimes in need of medical care. It is an eye-opener, a call to arms and a guide. Dr. Reznik is convinced that the medical establishment has drifted into a position of having betrayed its mission. He has the courage of his convictions, and is out to slay the dragon of mistreatment that people very often experience once they are caught up in the medical machine. And he tells you how you can fight back on an individual level. The cost of health care has blown out, and is continuing to rise. Dr. Reznik has persuaded me that much of this money is wasted on useless and unnecessary procedures. Indeed, many of these expensive activities are more likely to harm than to help the patient. He cites impressive authorities to back up his claims. It seems to me that his book should be read by policymakers, who might consider saving several fortunes, both for the taxpayer in general, and the individual victim. Why should patients suffer, and taxpayers slave away, just to ensure the profit of the health care industry? I consider it an honor to have edited this immensely useful guide to better health despite the worst the medical world can do.
Bob Rich, Ph.D., MAPS, AASH |
